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Effective Date: 
11/2019

Documents

 

Instructions

Updated: 11/2019

 

Purpose

Form 3048 is completed to notify applicants if they are eligible for the Title V Fee-for-Service Program, Primary Health Care Services Program or Epilepsy Program benefits.

Form 3048 is also completed to notify clients of the Title V Fee-for-Service Program, Primary Health Care Services Program or Epilepsy Program benefits to report changes in their situation and their liability if they fail to report changes.

 

When to Prepare

Complete the form for individuals applying for the Title V Fee-for Service Program, Primary Health Care Services Program or Epilepsy Program benefits.

 

Number of Copies

Complete an original and one copy.

 

Transmittal

Give the original form face-to-face or mail the form to the individual applying for assistance. File a copy in the case record.

 

Form Retention

Keep the case record copy for three state fiscal years after eligibility begins. However, eligibility is valid for a maximum of 12 months.

 

Detailed Instructions

Complete the information listed on the form.